Pulmonology Coding Alert

Hint: Watch out for changes to exclusions also in ICD-10 codes

As a pulmonology coder, you're very likely to encounter cases of pneumonia due to Streptococcal pneumoniae. Be proactive and bone up on how to report pneumonia caused due to S. pneumoniae when ICD-10 codes are brought into effect.

When a diagnosis of pneumonia due to S. pneumoniae is made by your pulmonologist, you will most probably encounter the following clues in the documentation:

Symptoms such as fever (R50.9, Fever, unspecified); cough (R05, Cough); sputum that is yellow or brown in color (R09.3, Abnormal sputum); shortness of breath (R06.02, Shortness of breath); and pain in the area of the chest during breathing (R07.1, Chest pain on breathing). In older patients, you might often see delirium and confusion as part of the symptoms.

Upon examination, your pulmonologist might record coarse or crackling breath sounds along with presence of wheezing. Your pulmonologist will order a chest X-ray to ascertain the reason for the symptoms the patient is experiencing and to know the cause for the altered breath sounds. Your pulmonologist might also resort to ultrasonography or a CT scan.

Procedure heads up: If any of the above mentioned radiological techniques confirms the presence of fluid in the pleural space, your pulmonologist might perform a thoracentesis to tap the fluid and send it for analysis. You report the procedure using 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent).

Your pulmonologist might also collect a sputum sample for analysis in the laboratory. He might also draw a blood sample to check for increase in WBC count that is suggestive of an infection. He may also draw an arterial blood sample to check for arterial blood gases to ascertain the efficiency of exchange of blood gases.

In addition to these tests and diagnostic methods, if an abnormality other than pneumonia is suspected (e.g., lung abcess), your pulmonologist might also resort to bronchoscopy to examine the trachea and the bronchi. You report the procedure using 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) unless other interventions (e.g., biopsy) are performed.

Note Exclusions to 481 While Using ICD-9 Codes

When your pulmonologist arrives at a diagnosis of pneumonia due to S. pneumoniae, you need to report the diagnosis with 481 (Pneumococcal pneumonia [streptococcus pneumoniae pneumonia]). This diagnosis code in ICD-9 for pneumonia also includes lobar pneumonia where the causative organism is not specified.

However, this ICD-9 code does not include pneumonia caused due to congenital, allergy, aspiration, rheumatic, lipoid and ventilator associated pneumonias and they have to be reported using appropriate CPT® codes.

Observe Exclusion and Descriptor Changes in ICD-10 Codes

When ICD-10 codes come into effect, 481 in ICD-9 codes crosswalks to J13 (Pneumonia due to Streptococcus pneumoniae) in ICD-10. This code in ICD-10 also includes bronchopneumonia due to S. pneumoniae.

ICD-10 coding guidelines for J13 specify that any associated influenza (J09.X1, J10.0-,-J11.0-) or associated abscess (J85.1) should be coded first if it is present with pneumonia due to S. pneumoniae. The exclusions to J13 are similar to the exclusions to 481 in ICD-9. However, lobar pneumonia due to an unspecified organism that is included under 481 in ICD-9 is not covered under J13 in ICD-10 and has to be reported separately using J18.1 (Lobar pneumonia, unspecified organism).

Example: A 57-year-old female patient presents to your pulmonologist with complaints of severe cough with copious amounts of brownish sputum. She also complains of fever with chills, chest pain especially when she is breathing. Your pulmonologist performs a thorough history taking and examination of the patient. Upon auscultation, your pulmonologist notes dull breath sounds and dull percussion note.

Your pulmonologist collects a sputum sample, withdraws a blood sample and sends it over to the lab for analysis. He also orders a chest x-ray. Your pulmonologist also performs a bronchoscopy to examine the trachea and the bronchi. The lab results confirm an infection caused due to S. pneumoniae.

Based on the diagnostic findings and lab findings, your pulmonologist is able to confirm a diagnosis of pneumonia caused due to S. pneumoniae. You report the diagnosis with J13.